Suicide ranks tenth among all causes of mortality in the US, accounting for over 38,000 deaths in 2010. Suicide attempts result in 600,000 emergency room visits and nearly 200,000 hospitalizations each year. Reducing this potentially preventable morbidity and mortality is a public health priority. Recent developments create an opportunity to evaluate population-based selective prevention programs for suicidal behavior. First, increasing use of standard depression severity measures will allow timely and efficient identification of people at risk for suicidal behavior. Second, efficient and scalable intervention (both structure risk assessment / care management programs and low-intensity emotion regulation skills training) have shown promise for reducing risk of suicide attempt in at-risk populations. Third, the NIMH-funded Mental Health Research Network has established a nationwide infrastructure large enough to test prevention programs. We propose a large, pragmatic trial to examine two specific selective prevention programs. The trial would be conducted in three or more large, integrated health care systems, enrolling approximately 16,000 adults for whom responses to item nine of the PHQ depression scale indicate elevated risk. Participants will be randomly assigned to usual care or one of the two prevention programs: a systematic outreach and care management program including structured assessment linked to specific care pathways. This would be based on a model successfully implemented at Henry Ford Health System. The assessment component would be informed by the recently developed Columbia Suicide Severity Rating Scale. Care pathways would include specific guidance regarding type and timing of recommended service. Electronic medical records will be used to support and monitor intervention quality. Outreach and assessment will continue through the one-year intervention period, with frequency depending on risk level; an online psychoeducational program focused on development of emotion regulation skills and prevention of suicidal behaviors, supported by coaching to promote engagement and adherence. The online program will incorporate components of Dialectical Behavior Therapy shown to mediate treatment effects on suicidal behaviors. Based on previous research with online interventions, we anticipate that coaching support will be necessary to promote initial engagement and continued participation. This coaching will be delivered by telephone and/or secure online messaging following a specific motivational enhancement protocol. Both programs would be intended as supplements to usual care, in addition to any risk assessment or treatment provided by primary care or mental health providers. The primary outcome will be documented suicide attempt during the following year - ascertained automatically using computerized records. A pragmatic trial of selective prevention of suicide attempts would fill a major gap in current suicide prevention efforts. Methods developed through such a trial could dramatically accelerate suicide prevention research. PUBLIC HEALTH RELEVANCE: A large pragmatic trial in three or more large health systems will evaluate the effectiveness of two programs to prevent suicide attempts among patients who report suicidal ideation on routine depression questionnaires. One program includes an online program to develop emotion regulation skills, supported by outreach and coaching. The other program includes systematic outreach to assess risk and encourage follow-up care.